The exquisite witness of a doctor, patient, husband, father.
Write as if you were dying. At the same time, assume you write for an audience consisting solely of terminal patients. That is, after all, the case. What would you begin writing if you knew you would die soon? What could you say to a dying person that would not enrage by its triviality?— Annie Dillard, The Writing Life (reviewed)
When Breath Becomes Air by Paul Kalanithi. Random House, 228 pp.
Paul Kalanithi had his life mapped out: 20 years of medical practice followed by 20 years of writing. Amidst that span, marriage and children, vacations and celebrations—plenty of time to repair the strains in his marriage caused by his tenacious pursuit of medical excellence. Found riddled with cancer late in his surgical residency, already a gifted neurosurgeon at age 36, he soldiered on for a time. While terminal himself, he operated on others.
Finally lacking the endurance for surgery, he concentrated on writing When Breath Becomes Air. In just under two years left to him, he wrote about his cancer treatments, about medicine as a high calling, about his past and ongoing life. He also became a father, nine months before he died, at age 37.
His cancer responded well to initial treatment, but returned. He explains his reaction to seeing those scans, which told him his end was coming fast:
I was neither angry nor scared. It simply was. It was a fact about the world, like the distance from the sun to the earth. I drove home and told Lucy.
His widow, Dr. Lucy Kalanithi, who wrote his book’s epilogue, elaborated for an interviewer (video below) about their complex reaction:
We’d seen it happen to so many people and witnessed and helped people through it. The reaction wasn’t so much “Why me?” We sort of felt, “Now it’s our turn to face this.” The best and worst part was that knowledge.
Few have been more prepared than Kalanithi to make sense of mortality. Growing up in Arizona, the son of a cardiologist, he’d planned to be a writer partly because of how hard his father worked. The price of medicine seemed too high. His mother, trying to overcome poor local schools, inadvertently kindled his literary ambitions when she found a college prep reading list. She made him read George Orwell’s novel 1984 at age ten. At Stanford University, he earned undergraduate and master’s degrees in English, along with an undergraduate degree in human biology. Afterward, at the University of Cambridge, he added a master’s in the history and philosophy of science and medicine. He then attended medical school at Yale—and picked perhaps the most demanding medical specialty, neurosurgery, returning to Stanford for his residency and a postdoctoral fellowship in neuroscience. He’d work as a surgeon and professor.
Weaving stories of surgeries he performed or treatments he witnessed with his own experiences as a patient, Kalinithi reveals himself not only as intelligent but as deeply empathetic to patients. Like the rest of us, as a patient himself he had fine doctors and fair—and one awful resident who almost killed him, it seemed as much from ego and lack of empathy as from inadequate experience. When Breath Becomes Air might be assigned in medical schools to address what seems a vexing nub: always building technical expertise while blending that skill with one’s humanity. He writes:
Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient’s life worth living, and planning to save those things if possible—or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination. . . . The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients.
One of his medical school friends killed himself after losing a patient in surgery. In a case Kalinithi witnesses, an adorable eight-year-old boy with a brain tumor is saved, only to return at age twelve, a violent monster—his hypothalamus had been slightly injured in the procedure. Few surgeons could have succeeded: one millimeter had made the difference between his living a normal existence and having to be institutionalized.And what of Kalanithi himself? He wrote this book, every word and line, facing death. Trained to fight death, he fought, but paradoxically at the same time had to accept. He’s like a jet pilot who has lost his engines and is trying to glide for as long as he can, while trying to avoid causing harm below in his inevitable crash, while seeing for the last time life’s ordinary and extraordinary beauty. A lesser writer might have exhorted his readers, but Kalanithi focuses on his experience and on rendering it precisely. This is the gift. The person, the writer, who can do this is exhortation enough.
But as well as portraying, he reflects, as he clearly did in life, and possesses the means to do so. He’d already moved from a long sojourn in “ironclad atheism” to an awareness that science cannot explain the central aspects of human life: “hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.” These emotions and emotional qualities are encoded, of course, in religion, which seeks to ascertain human truths. Today’s militant atheists seem speciously drawn to the obvious absence of a physical God, without awareness that the Bible itself documents an evolution in understanding and encouraging what’s holy within humans. As Kalanithi tries to explain:
Yet I returned to the central values of Christianity—sacrifice, redemption, forgiveness—because I found them so compelling. There is a tension in the Bible between justice and mercy, between the Old Testament and the New Testament. And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it. The main message of Jesus, I believed, is that mercy trumps justice every time.
One is tempted to lament the body of work—the saved lives, the brilliant articles, the profound books—Kalanithi would’ve produced. And he himself reflects on this. But here it is. Here is what he got, and what he was able to give us. A distillate. Here is profundity with a light touch, philosophical gravity lightened by living breath, prose of spare beauty.
This exquisite book centers you. Likewise its lesson for writers is quite simple and quite sobering: be as funny as you can, be as experimental as you desire, be as traditional as you wish, but never be trivial.
You that seek what life is in death,
Now find it air that once was breath.
New names unknown, old names gone:
Till time end bodies, but souls none.
Reader! then make time, while you be,
But steps to your eternity.
—”Caelica 83″ by Baron Brooke Fulke Greville (1614–1621)
[An excellent excerpt, with photos, video, and voice recording is Paul Kalanithi’s Spring 2015 essay in Stanford Medicine “Before I Go.” Other essays are linked off his web site, url above.]